Head and neck (H&N) cancers include those of the paranasal sinuses, nasal/oral cavities, salivary glands, pharynx, larynx, and upper cervical lymph nodes. Fifty-three thousand new diagnoses of H&N cancers were predicted in the United States in 2019 (National Cancer Institute, 2020a). Management of H&N cancer is multimodal and complex, including surgery as a primary intervention, possible radiation therapy and/or chemotherapy as adjunctive interventions. Adverse effects of treatments include reduced cervical range of motion (ROM), extremity and core strength, posture and functional walking capacity (Al-Kindi & Oliveira, 2016). The long-term impact of reduced physical functioning can be effectively addressed by home healthcare (HHC) rehabilitation clinicians to diminish the negative impact on long-term quality of life (QoL).
Rehabilitation professionals have a vast skill set that incorporates anatomy, physiology, and exercise prescription to educate and treat this population of patients across the survivorship continuum. There is strong evidence of the physiological benefits of exercise/physical activity to treat adverse effects caused from H&N cancer treatments. Examples include: reduced stress, anxiety and depression, improved immune function (National Cancer Institute, 2020b), improved cardiopulmonary function, increased muscle strength and endurance (Warburton et al., 2006), optimized pain control, and reduced risk of acquiring comorbidities. Appropriate assessment and intervention delivered at the appropriate time in the survivorship continuum promote functional independence and QoL in this patient population.
Physical therapists (PTs) are an important part of the multidisciplinary team in the HHC setting, promoting postsurgical recovery through functional mobility training to optimize independence and providing individually dosed prescriptive exercise. This discipline is well positioned to identify deviations from baseline function throughout the continuum of care and address potential needs as they arise. Regular and timely communication with other members of the multidisciplinary team is another essential function of PTs, promoting patient advocacy as well as referral to other clinical professionals when warranted.
In addition to ROM, strength and function assessments, considerations for postoperative evaluation in the HHC domain include functional outcome measures such as the Neck Disability Index (Shirley Ryan Ability Lab, 2015) and/or Disability for Arm and Shoulder (Shirley Ryan Ability Lab, 2014). As the Six Minute Walk Test may prove challenging within the HHC setting, a suitable alternative is the Two Minute Walk Test (Bohannon, 2017). Assessment of grip strength is useful for the purpose of determining global strength as well as its ability to determine frailty (Bohannon, 2015). Assessment of QoL is an essential component of a comprehensive evaluation, options include: The Functional Assessment of Cancer Therapy - Head and Neck (List et al., 1996) and the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (European Organization for the Research and Treatment of Cancer, 1970).
Subacute (4-6 weeks) HHC rehabilitative interventions should include varied modes and types of exercise (Table 1). Additionally, manual therapeutic interventions and education on topics such as expectations throughout cancer treatment, home safety, and energy conservation are warranted. Lymph node removal may result in lymphedema; therefore, screening by a therapist can facilitate timely referral to a certified lymphedema clinician to enhance recovery.
Exercise prescription should focus on appropriate dosing. The mode of exercise should consider patient's needs and established goals. Frequency and duration recommendations should respect current American College of Sports Medicine guidelines of 150 to 300 minutes of moderate-intensity exercise per week (Campbell et al., 2019). Additionally, it is important to monitor baseline and exercising vital signs to ensure safety. One useful exercise intensity measure that could be used is the BORG perceived exertion scale (Borg, 1998).
The HHC therapist should also remain acutely aware of problems related to wound healing, and promptly address concerns with the surgeon. Daily scar massage techniques can be taught at 4 to 6 weeks post-op, provided the scar is clean, dry, and intact. Trismus (reduced mouth opening of less than three fingers width) is a common problem and can contribute to reduced oral intake and poor nutrition. Active jaw opening ROM, stretches and lateral glides, as well as intervention with Therabite(R) (Atos Medical, 2020), can positively impact outcomes. Intraoral scar massage can also improve jaw ROM and can begin after full healing and as directed by the surgeon. In cases where fibular bone grafting has occurred to reconstruct areas of the jaw, the donor site (ankle) must also be evaluated and treated for ROM and strength deficits. Xerostomia (dry mouth) and difficulty swallowing are also common postoperative concern, requiring referral to a speech language pathologist, though mouthwashes and oral sponges can provide temporary relief.
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